Pharmacy Vaccine Consent Form

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Name* This field is required.

First Name

Last Name

2

Date of Birth* This field is required.

Date

3

Sex* This field is required.

FemaleMale

4

Phone Number

Area Code

Phone Number

6

Primary Care Provider (PCP) Name

First Name

Last Name

7

PCP Phone Number

Area Code

Phone Number

8

Are you sick today? If unsure, speak to the pharmacist now.

YESNO

9

Do you have any allergies to medications, food, latex, or a vaccine component?

YESNO

10

Have you ever had a serious reaction after receiving a vaccination?

YESNO

11

Do you have a long-term health problem with heart disease, lung disease, asthma, kidney disease, metabolic disease (diabetes), anemia or other blood disorders?

YESNO

12

Do you have cancer, leukemia, HIV/AIDS, or any other immunological disorder?

YESNO

13

Do you take cortisone, prednisone, other steroids, or anticancer drugs, or have you had radiation treatments?

YESNO

14

Have you had a seizure, brain, or other nervous system problem?

YESNO

15

During the past year, have you received a transfusion of blood or blood products, or been given immune (gamma) globulin or an antiviral drug?

YESNO

16

Have you received any vaccinations in the past 4 weeks?

YESNO

17

Was this form completed by someone OTHER THAN the patient?

YESNO

18

Form completed by?

First Name

Last Name

19

SignatureBy signing you agree to the Consent to Vaccination.

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